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Copyright ⓒ 2009 Journal of Korean Neurotraumatology Society 103

J Kor Neurotraumatol Soc 2009;5:103-105 ISSN 1738-8708

Penetrating Orbitocranial Metallic Foreign Body Injury - A Case Report -

Sang-Soak Ahn, MD, Young-Jin Song, MD and Ki-Uk Kim, MD

Department of Neurosurgery, Dong-A University College of Medicine, Busan, Korea

Penetrating orbitocranial injury caused by metallic foreign body is uncommon and often cause serious damage without prompt treatment. We present our experience with penetrating orbitocranial injury caused by metallic foreign body and review the outcome of surgical management and prognosis. We report a case of a 52-year-old man who presented with penetrating orbitocranial injury caused by metallic foreign body on his left periorbital area. Artifacts caused by the pene-trating metal ring on computed tomography (CT) obscure the actual brain damage along the path of penetration. The patient deteriorated in the emergency room and subsequently received surgical intervention. The present report indicates that good result can be achieved by early diagnosis of intracranial injury and by the removal of foreign body. Based on this experience, we recommend prompt surgical intervention with early CT evaluation to determine the extent of brain damage and surrounding damages. (J Kor Neurotraumatol Soc 2009;5:103-105) KEY WORDS: Craniofacial·Penetrating·Foreign body·Surgery.

Introduction Penetrating orbitocranial injury is uncommon and often

cause serious damage to the brain without prompt treat-ment.1,3-7,10,11) Usually knives are the common objects. How-ever, nails, spikes, iron rods, pencils, scissors, fan blades, and screwdrivers have been reported as objects causing stab wound.4) Foreign bodies that penetrate both orbit and cra-nium can cause injury to eye and brain. These foreign bodi-es pose problems in management as there is controversy regarding whether to operate or treat conservatively; and when operation is decided upon, what is the optimal timing and correct surgical approach? We report a case of penetrat-ing orbitocranial injury caused by metal ring and discuss the diagnosis and the surgical management.

Case Report

A 52-year-old man admitted with penetrating orbitocr-

anial injury caused by metal ring on his left periorbital area.

The patient was a factory worker using metallic gun, then, as a trouble of the gun he has had a periorbital injury.

On physical examination, there were bruising and swell-ing of upper eyelid, ecchymosis of conjunctiva and blood in the anterior chamber of the left eyeball. Ocular move-ment and pupillary reflexes, and light perception were nor-mal. The mentality of the patient was slightly lethargic st-ate. And other neurological deficiency was not found.

Skull radiograph showed a round metal ring in the ante-rior cranial fossa, nose, zygoma, medial and lateral orbital area. Computed tomography (CT) scan of the brain and or-bit demonstrated the metal ring to be lodged partly in the left orbit and partly in the left frontal lobe of the brain, hav-ing penetrated the frontal sinus. But, artifacts caused by the penetrating metal ring on CT obscured the actual brain dam-age along the path of penetration(Figure 1). Intravenous antibiotics (cephalosporin and metronidazole) were used im-mediately. The patient developed no fever, no meningism and no cerebrospinal fluid (CSF) leakage, but, gradually, about one hour after, his mentality was decreased to drowsy. As artifacts from metal objects obscured the actual brain damage, choice of therapeutic strategy was difficult. So the patient transferred to the neurosurgical unit, where urgent operative removal of the retained metal ring was decided upon.

A bicoronal scalp incision was made on frontotemporal

Received: February 6, 2009 / Revised: July 13, 2009 Accepted: September 29, 2009 Address for correspondence: Ki-Uk Kim, MD Department of Neurosurgery, Dong-A University College of Medi-cine, 1 Dongdaeshin-dong 3-ga, Seo-gu, Busan 602-714, KoreaTel: +82-51-240-5241, Fax: +82-51-242-6714 E-mail: kukim@daunet.donga.ac.kr

Orbitocranial Metal Injury

104 J Kor Neurotraumatol Soc 2009;5:103-105

area. The bone flap was made sufficiently to expose the dura of the frontal lobe and the orbit. The foreign body was identified and removed meticulously. The metal ring was removed from the entry site under direct visualization (Figure 2). We fractured frontal bone with fragmentation and opened frontal air sinus. We prefered to reconstruct the anterior skull base by using two layers of tissue for closure

as well as intervening structural support. The first tissue layer was the primary dural repair, and the second was the vascularized anteriorbased pericranial flap. Cranialization of the frontal sinus was done, and mucosal remnants of all sinuses were removed for prevention of mucocele formation.

After surgery, the patient recovered well and no fever, no meningism and no CSF leakage were found(Figure 3).

B CA D

FIGURE 1. Preoperative simple X-ray (A, B) and CT scan (C, D) demonstrate the position of the metal ring. CT reveals marked arti-facts along the trajectory of penetration (C).

FIGURE 2. (A) Operative fieldshows exposure of periorbital ar-ea and frontal lobe. Frontal cra-niotomy has exposed the metalring, seen to be entering the fron-tal lobe of brain; (B) removed me-tal ring.

A B

B A

FIGURE 3. Postoperative sim-ple X-ray (A) and CT scan (B) de-monstrate frontal lesion.

Sang-Soak Ahn, et al.

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The postoperative course was uneventful. Two weeks post-operatively, the patient was discharged without neurolog-ical deficits.

Discussion This type of penetrating orbitocranial injury is unusual.

Previously reported cases showed that penetration occur-red most commonly through the orbital roof and superior orbital fissure with no apparent ocular damage.9) Failure to recognize cerebral damage following penetrating orbital inju-ries, especially when there is retained foreign body, can lead to serious life-threatening complications. Cerebral hemor-rhage, meningitis, and abscess formation were the most com-mon causes of mortality and morbidity.1,4,6,9) It may in-crease the risk of brain abscess formation or meningitis th-at the presence of a roof fracture with a dural laceration re-sulting in a CSF leakage and the presence of pneumoceph-alus.1,3,4,6,8-11) In this case, penetrating injury caused dural laceration and fracture of frontal sinus, but the patient re-covered well without any postoperative complications.

The most appropriate management in the field is to le-ave the object in situ and transport the patient to the trauma center carefully.3,6,10,11) Management of patients with orbit-ocranial injuries and foreign bodies in situ should follow basic surgical principles, including removal of the object under direct vision in order to reduce further brain tissue damage by the foreign bodies catching on bone fragments. Hematoma evacuation followed by careful hemostasis al-ong the trajectory, and meticulous dural closure to reduce the possibility of cerebrospinal fluid fistula are manda-tory.3,4,6,9,10) Metal materials and other missiles with extr-acranial components must be removed and prophylactic antibiotics should be considered.2,6,9)

CT is typically the first-line radiologic examination in the emergency room for head-injured patients.3,4,6,8-10) In general, CT shows excellent details in bone and average value in soft tissue in case of the orbitocranial lesion. If a bony injury is suspected, axial and coronal views should be obtained. The coronal CT scan provides a good view of

the orbital floor, roof, and cribriform plate and allows detec-tion of intracranial or sinus cavity penetration.4) However, scanning artifacts from metal objects can sometimes limit visualization of brain tissue and brain damage along the trajectory of the penetrating object.6)

Conclusion

In conclusion, penetrating orbitocranial injury caused by

metal ring is ususally rare but sometimes may leave fatal events. Early CT scan and emergent surgical intervention is necessary if there is to be any chance of saving the life of the patient.

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